ACR Appropriateness Criteria® Suspected Physical Abuse-Child: Update 2025

For suspected physical abuse in infants and toddlers (<24 months), a radiographic skeletal survey and noncontrast head CT are usually appropriate first-line imaging, even if no injuries are apparent. These studies often reveal occult fractures or intracranial hemorrhages. For children >24 months without neurologic or visceral signs of injury, imaging is more targeted: radiographs of areas of concern are obtained, and skeletal surveys are used selectively, reflecting the lower yield of occult injuries in this older group. Neurologic symptoms or signs of head trauma warrant immediate neuroimaging; noncontrast head CT is the first-line acute study, with MRI reserved to further characterize brain injuries or subtle findings not seen on CT. For suspected visceral injury, contrast-enhanced abdominal CT is usually appropriate to detect internal injuries. A skeletal survey remains fundamental for detecting occult fractures in young children, and if initial studies are negative, a repeat skeletal survey after about 2 weeks is usually appropriate to identify healing injuries. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.